Post Term pregnancy

Dr. Mesfin A.

12/02/2023 By Mesfin A. (MD) 1

 Out line
• Definition
• Incidence
• Common causes and Risk factor
• Maternal complications and Fetal complications
• Diagnosis and Mgt options of post term pregnancy

12/02/2023 By Mesfin A. (MD) 2

 Definition
• Post-term-- A pregnancy that extends 42
0/7 weeks or 294 days from LMP OR
EDD +14 days
• Post date- is pregnancy lasting beyond the
estimated due date at 40 weeks.
• “Post mature” is reserved for the pathologic
syndrome in which the fetus experiences placental
insufficiency and resultant IUGR .

12/02/2023 By Mesfin A. (MD) 3

 Incidence
• Limited reliability with LNMP to determine accurate post-
term incidence
• Variations in timing of ovulation
• Irregular cycles
• Use of oral contraceptives
• BY LMP : 7.5 % (3-17%)
• BY USG : 2.6 % (2-7%)
• BY LMP + USG : 1.1 %

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 Common causes:

1. Wrong date : poor recall or variation in follicular

phase
2. Biologic variability: hereditary
3. Fetal factors: Anencephaly, male sex
4. Placental factor: sulfatase deficiency
5. Maternal factors: Primgravida, past prolonged
pregnancy, elderly
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 Risk factor
• Prim parity
• Prior post term pregnancy …
– After one Post term pregnancy, the risk is increased 2x-
3x
– The risk of recurrence is 4x after 2 prior Post
term pregnancies
• Male fetus,
• Genetic factors….maternal
• low socioeconomic status,
• Maternal weight gain and Obesity
• Smoking is associated with prolonged pregnancy

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 Cont…
• Associated with both fetal and maternal risks
• Perinatal mortality (ie, stillbirths plus ENND)
– At ≥42 weeks of gestation is twice that at term
• Incidence of fetal mortality for all groups is as follows:
– 40-41 weeks’ gestation: 1.1%
– 43 weeks’ gestation: 2.2%
– 44 weeks’ gestation: 6.6%

– As GA incr. fetal mortality incr. for post-term preg.

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 Maternal complications
Related to Macrosomia and interventions

Labor dystocia(difficult delivery)  operative

interventions
Severe perineal injury related to macrosomia

Doubling in the rate of cesarean delivery.

PPH

 A source of extreme anxiety for the pregnant woman

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Outcomes in Postterm pregnancies (42 weeks or greater) compared with
pregnancies delivered at 40 weeks
40 Weeks Post-term
(n = 8135) (n = 3457)
Factor a (%) (%)
• Meconium 19 27
• Oxytocin induction 3 14
• Shoulder dystocia 8 18
• Cesarean delivery 0.7 1.3
• Macrosomia (> 4500 g) 0.8 2.8
• Meconium aspiration 0.6 1.6

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 Why complication?
Two scenarios
1. Placental function continues  Macrosomia
2. Placental senescence(aging)  Utero placental
insufficiency impairs the transfer of oxygen fuels and the
disposition of wastes Dysmaturity
• Is the root cause for increased morbidity and mortality

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 1. Macrosomia
– Commonest outcome (75%).
– Occurs if placental function is maintained.
– Complications associated with fetal macrosomia
include
1. Prolonged labor
2. CPD
3. Shoulder dystocia with resultant risks of
orthopedic (eg, clavicular fractures) or neurologic
injury (eg, brachial plexus palsy)
 Macrosomia is far more common in post term than
term pregnancies
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 2. Dysmaturity syndrome
• Is observed in 20-30% of post-term infants & in 3% of term
infants.
• Manifestation of chronic IUGR due to placental insufficiency
• long, thin, malnourished infant, Loss of subcutaneous
fat
• Meconium staining
• Peeling skin- Dry, wrinkles, cracked skin.
• Unusual degree of alertness, have a "wide-eyed" look.
• Long nails
 Fetal hypoxia & Meconium aspiration syndrome.

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 Complications of post maturity syndrome

- Umbilical cord compression

- Increased fetal heart beat abnormalities
- Meconium aspiration
- Short term complications: hypoglycemia, seizure,
respiratory insufficiency
- Long term complications: neurologic sequela

12/02/2023 By Mesfin A. (MD) 14

Management of Post Term Pregnancy

• Management options depend on:

– Gestational age,
– Absence/presence of maternal risk factors and / or
– Evidence of fetal compromise, and
– Maternal preferences .
 Successful management depends on effective counseling
of women and their full involvement in the decision
making process.
12/02/2023 By Mesfin A. (MD) 15
 Initial Evaluation
• Confirm the gestational age
• Review the prenatal case document
• Do physical examinations to:
• Estimate fetal size, ascertain viability
• Assess the adequacy of the pelvis, and favorability of
cervix (Bishop‟s score)

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 Confirm the gestational age by
1. History:

– Define the LNMP & determine the regularity of

menses.
– Use of hormonal contraceptive method

– Date of quickening

– Date of conception(e.g ovulation induction and

assisted reproductive treatment)
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 2 . Physical Examination
• First trimester pelvic examination to determine uterine size
• Symphysis fundal height in centimeter compares favorably
with gestation age at approximately 20-34 weeks of gestation.
• Detection of fetal heart tones
• o Fetoscope at 18-20 wks.
• o Doppler at 10-12wks

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 Management options
1. Either expectant management or
2. Induction of labor
• Which is better?

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 Direct termination
 Delivery is initiated if fetal assessment is not reassuring
or spontaneous labor does not occur
 Induce at:
• 42 completed weeks in all cases with favorable cervix
• 42 completed weeks by ripening the cervix if
unfavorable cervix.
• 43 wks of gestation irrespective of cervical status

• Cesarean section if contraindication for induction or

vaginal delivery exists.
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 Management of Labor & delivery
• Patients are scheduled for induction from outpatient unless
otherwise induction on emergency ground or admission for other
obstetrical risk factors is indicated.
• First stage of labor: close follow by CTG monitoring or
– intermittent auscultation every 15 minutes in relations to
contraction.
• Second stage of labor: anticipate the following maternal and fetal
complications.
– Maternal: Shoulder dystocia, PPH, Genital (birth canal)
trauma,
– Fetal: Fetal distress, Meconium aspiration syndrome.
• Third stage should be managed actively.

12/02/2023 By Mesfin A. (MD) 21

 Intra-partum management
• Left lateral position

• Continuous electronic fetal monitoring

• Early ARM in active phase (hastens progress, detects

meconium)
• LUST C/S if CPD/ macrosomia, fetal distress

• Amnio infusion (750-1000ml NS/RL) –If meconium stained

liquor, variable decelerations
• Pediatrician called at delivery
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 Prevention

• Early routine ultrasound examination

• Sweeping/stripping of membranes at term if no
vaginitis, mal presentation or placenta previa

12/02/2023 By Mesfin A. (MD) 23

 THANK YOU.

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